The present invention relates to the field of pain management, including the field of pain management based on active ingredients that may have respiratory depressant side effects.
Among the active ingredients that may have respiratory depressant effects, the invention is specifically directed to opioid agonists and benzodiazepines.
Opioid agonists are substances whose effects are similar to opium, but not chemically related. Opioid agonists exert their effect by stimulation of opioid receptors. Complex formation opioid agonist/receptor causes a pharmacological response relative to the type of opioid receptor (also called opiate receptor).
Opioid agonists are used therapeutically for the treatment of pain, and are also used as a replacement during detox treatment.
A number of opioid agonists are commonly used. For example, a non-exhaustive list includes alfentanil, anileridine, apomorphine, buprenorphine, butorphanol, carfentanil, codeine, diamorphine (“Heroin”), dextropropoxyphene, dihydromorphine, fentanyl, hydrocodone, hydromorphone, levallorphan, levophenacylmorphan, levorphanol, methadone, morphine, nalbuphine, nalorphine, norlevophanol, oxycodone, oxymorphone, pentazocine, pethidine, propoxyphene, remifentanil, sufentanil, tramadol, etc.
In addition, a number of endogenous substances may be classified as opioid agonists: dynorphins, endorphins, endorphins, enkephalins, nociceptors, etc.
Opioid agonists may have many undesirable side effects including drowsiness, respiratory depression, constipation, nausea/vomiting, etc. Their use should be handled with care, especially in the hospital or any health care setting.
Treatment with opioid agonists pose many problems of misuse because they may be a substitute for hard drugs. Consequently, supply clinics require expensive security systems. Finally, the rapid addiction to this kind of treatment associated with long-term treatment resulting in increased doses may make the patient dependent, especially when the administration is “on demand.” As a result, an opioid agonist-based therapy requires strict regulation and strong involvement of medical staff, which is problematic in the context of cost optimization.
There are three main types of opioid receptors, mu (μ), delta (δ) and kappa (κ). These receptors are widely distributed in the brain and in some peripheral areas.
Opioid antagonists, in contrast to opioid agonists, are characterized by an inhibitory activity of at least one opioid receptor. They may be divided into two main classes: the specific opioid antagonists and non-specific opioid antagonists. Among the non-specific opioid antagonists are, in particular, naloxone, naltrexone and nalmefene.
In the case of opioid poisoning, to limit certain side effects, opioid agonists may be associated with opioid antagonists.
For the administration of opioids, injectable solutions are predominantly used today, especially in the hospital environment. This form of administration has a number of advantages, for example, the effect is very fast and bioavailability is quite well controlled. However, administration by injection is not perfect. In fact, in addition to the discomfort of the injection and the requirement of a professional for administration, some side effects are very pronounced including, but not limited to respiratory depression.
Benzodiazepines are used primarily for their main properties: hypnotics, anxiolytics antiepileptics, muscle relaxant, and amnesic.
A number of benzodiazepines are commonly used. For example, a non-exhaustive list includes alprazolam, bromazepam, chlordiazepoxide, clobazam, clonazepam, clotiazepam, clorazepate, diazepam, estazolam, flunitrazepam, loprazolam, lorazepam, lormetazepam, midazolam, nitrazepam, nordazepam, oxazepam, prazepam, temazepam, tetrazepam, triazolam, etc.
Benzodiazepines have many undesirable side effects including amnesia, abnormal behavior, tolerance, respiratory depression, etc.
Benzodiazepine antagonists, unlike benzodiazepines, are characterized by an inhibitory activity of the activity of benzodiazepines. The best known benzodiazepine antagonists is flumazenil.
In the case of benzodiazepines intoxication, to limit certain side effects, e.g., respiratory depression, benzodiazepines may be associated with a benzodiazepine antagonist.
In the context of this application, the term “active ingredients from the DR group” refers to active ingredients with at least one side effect of respiratory depression.
In the context of this application, the term “active ingredients from the ADR group” refers to active ingredients that counter respiratory depression induced by the active ingredients of the DR group.
Opioid agonists and benzodiazepines, for example, are active ingredients of the DR group with at least one side effect of respiratory depression.
Opioid antagonists and benzodiazepine antagonists, for example, are active ingredients of the ADR group that counteract respiratory depression.
Unless otherwise defined, each technical or scientific term used herein has the sa: meaning as commonly understood by one of ordinary skill in the art to which this disclosure belongs. In accordance with the claims that follow and the disclosure provided herein, the following terms are defined with the following meanings, unless explicitly stated otherwise.
“Active Formulation” include a formulation comprising one or more active pharmaceutical ingredients. The active ingredients may be formulated as a solution in which non-molecular dispersion. The active ingredients may also be formulated in a form modifying its properties, particularly those related to the passage of membranes and bioavailability; microcapsules, liposomes, fast acting forms, etc.
“Intranasal administration” is the administration of the active ingredients in the patient's nasal cavity. The active ingredients may be in different forms: gas, steam, microdroplets, suspended powder, etc. In one embodiment, the active ingredients are in aerosol form, e.g., in a suspension of fine solid particles in a liquid or gas, wherein the particles fall under 50 cm per second. Intranasal administration is also characterized by the fact that most of the active ingredients are absorbed by the nasal mucosa of the patient.
“Sequential administration” is the administration of one or more successive administrations of the active ingredients.
“Respiratory depression” is a side effect following the administration of several active ingredients, e.g., hypoxia tissue, increased carbon dioxide levels in exhaled air, reduced oxygen levels in the exhaled air, decreased respiratory rate, decreased breathing amplitude, etc.
“Undesirable side effect” is the effect of an active ingredient that it is not directly desired. The undesirable side effect may be limited by administering an amount of the active ingredient that counteracts the undesirable side effect.
“Independent administration” is when the administration is performed by the patient himself or herself without the intervention of a health professional. When the administration takes place in animals, it is understood that the administration is carried out by the breeder.
“Energy Source” is an independent energy source which may be useful to permit the independent administration as indicated above. The energy source is generally portable, and preferably incorporated into a portable system of the intranasal delivery device. For example, the energy source may be a battery, a source of photovoltaic energy, energy recovered from the patient, e.g., heat generated by motion, etc.
“Administration without any medical facility” means that a sequence of one or more successive administrations may take place without any supervision of a health professional. Optionally, the therapy may be prescribed by a health professional, while the administration itself takes place in a place where such professionals are neither present nor necessary.
“Initial stage” is the time period during which the first administration of the therapy is performed.
“Subsequent stage” refers to the time period that any administration after the first administration of the therapy is performed.
“Administration simultaneously/simultaneous administration” is the administration of at least two active ingredients. Alternatively, each active ingredient may be administered such that their pharmacological effect begin at the same time and/or are generally simultaneous. In another aspect, the active ingredients may be formulated as a mixture.
“Choice of administration” is when the patient receives an administration because the patient wants to.
“Information means” is an element whose function is to acquire and transmit information for decision making, e.g., a choice of administration. It may be a time counting means for measuring at least one biological parameter.
“Time counting means” refers to any means of measuring time intervals. It may include a clock, a stopwatch, a countdown timer, a microprocessor operating at a known frequency operation, etc.
“Biological parameter” refers to a patient's biological characteristic, which is in the form of a numerical value where quantifiable. For example, it may be oxygen saturation or respiratory rate.
“Device for measuring at least one biological parameter” is a device that produces a numerical value corresponding to a biological parameter of the patient.
“Device for measuring at least one biological parameter introduced concomitantly” is a device where at least one portion is located in the nasal cavity during at least the beginning of the administration.
“Patient signal means” is an element that emits a signal perceptible to the patient, thereby allowing the patient to obtain information on the choice of the administration. The signal may be a light signal. When the signal is positive, it means that active formulation containing active ingredients from the DR group without active ingredients from the ADR group may be issued. When the signal is negative, it means that active formulation containing active ingredients from the ADR group, but no active ingredients of the DR group may be issued. For example, when at least one of the information means transmits information to the signal processing unit opposing the link between the active formulation containing active ingredients of the DR group without active ingredients of the ADR group and the dispensing means, then the patient signal means transmits a negative signal to the patient.
“Liquid spray” is liquid capable of being transformed into droplets and/or microdroplets.
“Mixture of active ingredients” is the presence of active ingredients within a single storage space. The mixture may be in liquid, solid, or gas. In the case of a gas mixture, molecules of different active ingredients may be dispersed within the same storage space called a molecular mixture.
“Opioid agonist” is an active ingredient which acts on at least one opioid receptor in a manner similar to opium.
“Opioid antagonist” is an active ingredient which acts on at least one opioid receptor inverse to opium.
“Initial actuation system” refers to the first operation of the administration of therapy achieved by the patient wishing, to receive an initial administration. There may only be one initial actuation system during a single therapy.
“Subsequent actuation system” refers to subsequent operation of the administration of therapy achieved by the patient wishing to receive an administration. There may be one or more subsequent actuation systems during a single therapy.
“Portable device for intranasal administration” is a device that may be carried by the patient, and not as a burden that limits its mobility. In particular, the device may be so easily transported that a mere possibility of having to use it, e.g., in an emergency, justifies its portability. It may be arranged in a pocket, a hand, a bag, a box car glove, a handbag, a capsule resistant to water and/or sand, etc.
“Storage space” is an enclosed space containing an active formulation. In the enclosed space, air exchange with the outside is low or nonexistent, and cannot, in the short run, cause a qualitative and/or quantitative formulation. During use, the enclosed space may communicate with the outside.
“Linking means” refers to all the elements allowing communication between the storage space and the dispensing means. It may in particular be a mechanical barrier, e.g., a valve.
“Signal processing unit” is an element related to both information means and linking means. Information means sends information that is evaluated by the signal processing unit. Operation of the signal processing unit allows the signal processing unit to issue operation control signals to the linking means based on the assessment made.
“Excessive respiratory depression” is a state of respiratory depression wherein the risk/benefit of simultaneous administration of at least one active ingredient of the DR group and at least one active ingredient of the ADR group is not desirable. For example, when the measured biological parameter is oxygen saturation, respiratory depression may be considered excessive when the oxygen saturation value is lower than 85° h. In addition, when the biological parameter is respiratory rate, respiratory depression may be considered excessive when the value of the respiratory rate is less than 12 cycles of inspiration/expiration per minute.
“Removable storage space” is storage space that may be removed from the device without making it permanently unusable.
“Changeable storage space” is storage space that may be acquired, according to the regulations in force, regardless of the device. The changeable storage space may be withdrawn and replaced with new storage spaces including, where appropriate, the same active ingredients in order to reload the device.
“Dispensing means suitable for transmission of active formulations through the nasal mucosa” is an element or set of elements needed to bring active formulations in contact with the nasal mucosa.
“Power source” is a supply of electric current to the portable device. This electric current may be generated by, for example, a battery, a capacitor, means of collecting solar energy, means for collecting the patient's energy, e.g., mechanical energy or body heat, etc.
Despite the strong need for therapy with analgesic active ingredients such as opioid agonists and benzodiazepines, that need is limited by side effects, particularly respiratory depression. In the future, these therapies will present a number of improvements:                From an ergonomics of treatment point of view: secure management made easier, noninvasive administration, limit post-treatment harm, etc.        From a financial point of view: limit the intervention of the nursing staff, reduce hospitalization durations, reduce misuse impacting health systems, reduce costs of distribution networks, etc.        From a public health point of view: reduce respiratory depression, limit misuse; etc.        
In particular, there is a long felt need for a technical solution for delivering in an independent, controlled manner, by the patient himself without any medical facility, active ingredients used in the treatment of pain while at the same time managing the adverse side effects of such treatment. This need especially is especially felt by people, e.g., soldiers, journalists, adventurers, explorers, hunters, hikers, climbers, who are far from any medical personnel or treatment center, e.g., hospital, clinic, health center, etc. Indeed, these people are often found in places where the Objective dangers involving the maintenance of bodily integrity are quite significant, and the risk of inflicting traumatic injury is quite high. These people therefore need a single therapeutic solution enabling them to manage all kinds of situations where there is a manifestation of pain through proper administration of suitable products, while at the same time, avoid suffering from undesirable side effects.
Various efforts have been made to improve opioid therapy, but satisfactory results have yet to be obtained.
For example, Chinese application CN 102068697 describes combining an opioid agonist and an opioid antagonist in attempt to limit the adverse effects of the opioid agonist without impacting its effect. Specifically, the application teaches a nasal spray comprising a mixture of fentanyl/naltrexone. However, the application fails to describe limiting the number of administrations or any way of controlling the potential side effects once the opioid antagonist metabolizes.
U.S. Patent Pub. No. 2007/0186923, assigned to AcelRx Pharmaceuticals, describes a medical delivery device for the administration of opioid agonists in the oral mucosa. The device has a safety component which prevents opioid antagonist spill when attempting to recover the opioid agonist solution. The application is therefore a security system ensuring the neutralization of the effect of the opioid agonist composition in case of attempted hijacking, making the composition unusable. Under normal conditions, no mixing occurs between the opioid agonist and the opioid antagonist, and no antagonist administration takes place.
WO 2012024106, assigned to the University of Florida, describes a complex system consisting of acquisition of pharmacokinetic and pharmacodynamic data, algorithmic analysis, wherein the response may be variable. The application specifies that the oximeter is not considered a reliable device for detecting abnormality, and that other probes are preferred. In addition, the device is not transportable.
WO 1996040332, assigned to Go Medical, describes a medical device for intranasal administration of an opioid agonist. The device comprises an opioid agonist solution and other active molecules other than opioid antagonists, thus no opioid antagonist incorporation is envisaged. The application fails to describe limiting misuse, and only describes a control system wherein a patient uses “good faith.”
U.S. Pat. No. 4,464,378 describes methods of intranasal administration of antagonists and corresponding formulations, for example, in gel form. The objective expressed in this patent is to circumvent the difficulties encountered with the use of certain known products which showed insufficient bioavailability during oral administration. This patent describes formulating solutions, gels, suspensions, and ointments containing the opioid agonist-antagonist for intranasal administration.
U.S. Pat. No. 5,629,011 describes intranasal formulations of polar metabolites of opioid agonists in combination with an absorption promoter acting in the raucous membranes.
U.S. Pat. No. 5,767,125 describes a method of co-administration of an opioid agonist with an opioid antagonist. The opioid agonist is selected from morphine, codeine, fentanyl analogs, pentazocine, buprenorphine, methadone, enkephalins, dynorphins, endorphins, and alkaloids and opioid peptides which behave in the same way. The opioid antagonist is selected from naltrexone, naloxone, etorphine, diprenorphine, dihydroetorphine, and alkaloids and opioid peptides behaving in the same way. The product is administered to mice by intraperitoneal injection, but the patent raises the possibility of preparing formulations for oral, sublingual, intravenous, intramuscular, subcutaneous, and transdermal administration.
WO 2001058447 describes compositions containing an opioid agonist and an opioid antagonist that may be formulated for intranasal administration. It should be noted that here the opioid antagonist is coated with a substrate, e.g., a polysaccharide, to form microspheres to control its release on the mucous membranes so as to ensure the effect of the opioid antagonist during the effect.
U.S. Pat. No. 6,948,492 describes systems and intranasal delivery devices regarding controlling the minimum time between intranasal self-administration of a plurality of unit doses of a pharmaceutical composition. Unit doses contained in bottles are deposited on a support star around a hub that may rotate to advance the unit dosage after each use, but only after a certain predetermined time has elapsed. The support star is biased constantly to rotate and advance the bottles, the progression of which is retained by a metal spring and a shape memory alloy wire. The locking is controlled by a microprocessor which counts down between each administration. This patent does not describe co-administering an opioid agonist and an opioid antagonist, or another form of control preventing the inappropriate administration of the composition. Indeed, although it is possible for the disclosed device to self-administer subsequent doses of opioid composition, the dosage is not in a physiological condition to withstand such administration.
In summary, none of the solutions mentioned above resolve all the problems described above.
As will be discussed below, a device in accordance with the present invention solves the problems mentioned above.